Program: Anti-retroviral therapy (ART) to prevent mother-to-child transmission (PMTCT) of HIV | GiveWell

# Program: Anti-retroviral therapy (ART) to prevent mother-to-child transmission (PMTCT) of HIV

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Published: 2009

# In a nutshell

• The Problem: HIV can be transmitted from mother to child during late pregnancy, birth, and breastfeeding. In Africa, it is estimated that without anti-retroviral therapy (ART) 25-35% of HIV positive mothers pass the virus to their infants.
• The Program: ART for the mother and/or child, over a relatively short period of time, aiming to prevent transmission of HIV from mother to child.
• Track record: Randomized trials in the developing world have shown ART to cut mother-to-child transmission (MTCT) by approximately 40% on average.

## Sources

• 1.

"Based on a review of 13 cohort studies the risk of vertical transmission of HIV without antiretroviral treatment was estimated to be about 15-20% in Europe, 15-30% in the USA, and 25-35% in Africa." Volmink et al. 2007, Pg 4.

• 2.

"Principal investigators of all nine clinical trials undertaken in sub-Saharan Africa were asked to participate in this study; seven agreed to a combined analysis of their mortality data in children of HIV-infected mothers ... 3468 singleton children were included in this analysis ... By age 1 year, an estimated 35Â·2% infected and 4Â·9% uninfected children will have died; by 2 years of age, 52Â·5% and 7Â·6% will have died, respectively." Newell 2004.

• 3.
• "As higher maternal viral loads are associated with a greater risk of mother-to-child transmission of HIV infection, any intervention that substantially reduces viral load may decrease the likelihood of mother-to-child transmission." Volmink et al. 2007, Pg 5.
• "Antiretroviral drugs can reduce mother-to-child transmission of HIV in one of more the following ways 1) by reducing viral replication and thus lowering plasma viral load in pregnant women; 2) through pre-exposure prophylaxis of babies by crossing the placenta; and 3) through post-exposure prophylaxis of babies after delivery." Volmink et al. 2007, Pg 5.
• 4.

"The WHO recommends various initiatives to improve initial testing of pregnant women with, at minimum, a rapid HIV test at approximately 20 weeks gestation. Rapid testing has many advantages compared with laboratory-based ELISA testing, including avoiding the transportation of specimens and return clinic appointments for women to receive results, ensuring that women booking late in pregnancy receive their results prior to delivery, and saving time at busy clinics." Maheswaran and Bland 2009.

• 5.

"For universal treatment with 30% HIV-1 seroprevalence, the HIVNET 012 regimen would avert 603 cases of HIV-1 in babies, cost US$83,333, and generate 15,862 DALYs...For targeted treatment at 30% seroprevalence, HIVNET 012 would cost$141,922 and avert 476 cases at $298 per case averted or$11.29 per DALY. With seroprevalence higher than 3.0% for universal and 4.5% for targeted treatment, the HIVNET 012 regimen was likely to be as cost effective as other public-health interventions." Marseille et al. 1999, abstract.

• 6.

Volmink et al. 2007, abstract.

• 7.

"a single dose of NVP given to mothers in labour and babies immediately after birth seems to be effective and feasible." Volmink 2007, abstract.

• 8.

"Significant reduction in mother-to-infant HIV transmission in the intervention group was found in all eight studies, with a range of 33 to 67 percent reduction in transmission." Jamison et al. 2006, Pg 338 (Table 18.3).

• 9.

"Single-dose nevirapine (sdNVP) administered to women at the onset of labor and to infants within 72 h of delivery has been widely used in PMTCT programs throughout Africa owing to its feasibility and low cost, reducing transmission by approximately 40%, from a rate of 20% to 12%, at 6-8 weeks postpartum." Maheswaran and Bland 2009.

• 10.

"Short courses of antiretroviral drugs are effective for reducing mother-to-child transmission of HIV and are not associated with any safety concerns in the short-term ... The long term implications of the emergence of resistant mutations following the use of these regimens require further study." Volmink et al. 2007, abstract.

• 11.

"Pregnancy-related complications include a risk of pre-term delivery associated with combination ARV, stillbirth, hepatotoxicity in pregnant women (particularly those with CD4 counts >250 cells/mm3) taking NVP, gestational diabetes and pre-eclampsia. AZT has been linked to anaemia and neutropenia in infants." Maheswaran and Bland 2009.

• 12.

“Viral resistance in women and children previously exposed to ARV prophylaxis during PMTCT programs raises concerns regarding future ART in women and children.” Maheswaran and Bland 2009.

• 13.

"Prevention of mother-to-child transmission using a single dose of nevirapine in generalized epidemic settings (US $6 to$12 per DALY averted) stands out for its combination of well-documented high cost-effectiveness and significant avertable infections and deaths." Jamison et al. 2006, Pg 43.

• 14.

25 DALYs per infection averted: "The estimates of cost per disability-adjusted life year (DALY) saved assume a uniform 20 DALYs lost per infected adult (Murray and Lopez 1996) and 25 DALYs lost per infected child (Marseille and others 1999) and do not account for the increasing proportion of people living with HIV/AIDS in developing countries who will have access to antiretroviral therapy over the coming years." Jamison et al. 2006, Pg 344.

• 15.

See Jamison et al. 2006, Pg 341 (Table 18.4).